Basic Information
| Provider Information | |||||||||
| NPI: | 1275876971 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LONGORIA | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | JACOB | ||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3046 | ||||||||
| Address2: | |||||||||
| City: | MALVERN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193550746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9566324000 | ||||||||
| FaxNumber: | 9569614286 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 W EXPRESSWAY 83 | ||||||||
| Address2: | |||||||||
| City: | MCALLEN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785033045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9566324000 | ||||||||
| FaxNumber: | 9569614286 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2013 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Q9187 | TX | N | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | Q9187 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3714297-01 | 05 | TX | MEDICAID |